=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639557994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVINE ATANG MAYA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2015
-----------------------------------------------------
Last Update Date | 03/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 BENNING ROAD NE APT L23
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-467-8032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1515 BENNING RD NE APT L23
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20002-8529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-467-8032
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | HHA11070
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------